Doctors are the main barrier to computerizing records

WASHINGTON, D.C.—The biggest single obstacle to better measurement of health outcomes is a lack of electronic medical record (EMR) systems, said experts at a meeting here. And the primary barrier to adopting EMR technology, they said, is physician resistance.

Speaker after speaker at the Zitter Group Congress on Health Outcomes and Accountability recounted examples of how physician resistance had stymied attempts to implement EMR technology and health outcomes measures. The speakers' message to physicians was clear: Stop waiting for the perfect system and get involved with EMR technology now.

"Until we have the right technology in place, we cannot make the leaps and advances in outcomes and accountability that we'd like to make," said Mark Zitter, president of the Zitter Group, a San Francisco-based firm that provides education and training in health outcomes, research, measurement and management.

At Nash Health Care Systems in Rocky Mount, N.C., which began developing an EMR system more than five years ago, many practitioners still refuse to use the electronic record. Many physicians say that paper charts are easier to use and more trustworthy than electronic records, explained Guyla Evans, senior clinical systems analyst. She also said that physicians complain the process of implementing EMR is too complicated and worry that they won't be able to access patient information if the system crashes.

While he acknowledged that physicians have valid concerns about EMR technology, Chalmers M. Nunn Jr., ACP Member, a gastroenterologist and vice president of medical affairs at Nash General Hospital, said that he frequently reminds physicians that the paper file is not necessarily any more problem-free than the electronic record. "Paper files can be illegible, missing, incomplete, slow and disorganized," he said. "Plus, they take up lots of space and are labor intensive."

In addition, Dr. Nunn explained, Nash's electronic record system actually offers more security than paper records. The EMR system tracks who's using the system and what information is being accessed. Technical staff track these data on a regular basis and follow up on suspicious use of the electronic system.

Getting physicians involved

But no matter how well an EMR system functions technically, it is doomed to failure without physician support. Getting physicians involved early in the process will help tailor information systems to physicians' practice needs, said David J. Brailer, ACP Member, PhD, the CEO for Care Management Science Corporation in Philadelphia. At Nash, for example, physician input led developers to create a pen-based interface for the system. Many physicians at Nash can't type, and would not be able to use a system that requires them to do so.

Having physician participation at an early stage will also help ensure that the system is accessible. At Nash, for example, physicians can access patient information whenever and wherever they want, whether in the hospital, medical office or at home by modem. The EMR allows them to quickly view lab results, vital statistics, and data like the nurses report, radiology report and record of hospital stays. Physicians can also access decision-support tools like journals online or drug information via the organization's intranet.

A lack of physician participation and leadership can hurt even the best-planned EMR system. Brent James, MD, vice president of medical research at Intermountain Health Care, said that his health system has been stymied by a lack of clinical leadership in deploying electronic-based protocols throughout the system. While he's been able to prove that Intermountain saves millions of dollars when effective protocols are adopted, implementing them has not been entirely successful.

"It comes down to a problem with priorities," he said. One protocol failed, for example, because the lab didn't perform tests needed for the protocol. And a successfully deployed protocol designed by a physician at one Intermountain hospital failed when the attempt was made to duplicate the results at other hospitals in the system, he said.

"It's not an issue of motivation—physicians and nurses genuinely want to provide better care for patients," Dr. James said. But without a physician leader to promote a protocol's importance, the medical staff at other hospitals had too many other responsibilities to make it a priority, he said.

Incentives

Experts at the meeting said that one way to get physicians involved in EMR technology is to introduce physician profiling. Electronic record systems make it far easier to gather and analyze data used for profiling, something that interests most physicians.

"Feedback to physicians is a very strong incentive," said John M. Eisenberg, MACP, the administrator of the Agency for Health Care Policy and Research. "Doctors are high achievers, very data driven, and they want to excel and to know if they are doing a good job. We should take advantage of that." Comparing an individual's practice performance or treatment protocols against his or her peers', or against the medical center standard, can serve as strong incentive to using EMR and improving care, Dr. Eisenberg said.

Dr. Eisenberg warned that tying financial incentives to physician profiling can backfire by encouraging inappropriate behavior. For example, he said, financial rewards based on patient outcomes and cost of care may lead physicians to avoid caring for really sick patients, because sicker patients' poorer-than-average outcomes and higher cost of care might damage their profiling report and decrease their financial reward.

HealthPartners, a mixed model HMO based in Minneapolis, has attempted to motivate its physicians through online profiling, said Gail M. Amundson, ACP Member, an internist and associate medical director there. By logging onto the HealthPartners intranet, physicians and physician groups can access how their practice performance compares against the HealthPartners mean and best practice benchmarks.

Proposal would protect privacy of medical records

One federal law would replace the mishmash of state regulations governing confidentiality

Fueled by concerns over the privacy of electronic medical records (EMR), a new government proposal delineates measures for protecting confidentiality of these records, including civil and criminal penalties for unauthorized uses.

Proposed in mid-September by HHS Secretary Donna Shalala, the recommendations would be used to craft comprehensive federal standards for medical records confidentiality. Federal guidelines for the disclosure of medical records—mandated by the 1996 Kassebaum-Kennedy act—would replace the mishmash of state provisions that currently govern the use of medical records.

The Shalala proposal lists the growing use of the EMR as one of the motivations for a federal law on medical records privacy. It notes that computers render the concept of "location" of information nearly meaningless, and that federal guidelines are needed to ensure consistent regulation, particularly for patients who regularly cross state borders for their care.

The recommendations have received mixed reviews from members of the medical profession, who worry that the proposal gives too much or too little access.

Some advocacy groups are concerned that the proposal would allow police and other law enforcement agencies, including the FBI and CIA, to access electronic medical records. The Physicians Information Exchange, a physician-run corporation that addresses quality and cost issues relating to electronic medical record technology, has said that the proposal "could erode citizens' rights to privacy and lead to an abuse of police powers."

W. Ernest Rutherford, ACP Member, CEO and chairman of the Monroe, La.-based organization, said that patient confidentiality should be protected by a numerical identification system. In addition, he said, medical records should only be released to law enforcement officials after a court order has been issued.

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